Provider Demographics
NPI:1306037825
Name:SYNERGY MEDICAL SYSTEMS LLC
Entity Type:Organization
Organization Name:SYNERGY MEDICAL SYSTEMS LLC
Other - Org Name:SYNERGY RX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC,AO
Authorized Official - Prefix:
Authorized Official - First Name:LACY
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:541-342-4928
Mailing Address - Street 1:1710 WILLOW CREEK CIR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402-9192
Mailing Address - Country:US
Mailing Address - Phone:541-343-3758
Mailing Address - Fax:541-852-4120
Practice Address - Street 1:55 COBURG RD STE 105
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2433
Practice Address - Country:US
Practice Address - Phone:541-342-4928
Practice Address - Fax:541-342-4930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-08
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
ORRP00024123336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2079562OtherPK
OR274629Medicaid
OR274629Medicaid